Therapeutic approaches to the treatment of post traumatic stress disorder and substance use in adults and adolescents Natalie Peach 1, Katherine Mills 1, Emma Barrett 1, Vanessa Cobham 2, Joanne Ross 1, Sean Perrin 3, Sarah Bendall 4, Sudie Back 5, Kathleen Brady 5, Maree Teesson 1 1 NHMRC Centre of Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia 2 School of Psychology, University of Queensland, St Lucia, QLD, Australia 3 Department of Psychology, Lund University, Lund, Sweden 4 Orygen National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia 5 Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
Outline What are trauma and PTSD? How common are trauma and PTSD among people with substance use disorders? Why are we concerned? Why do they co-occur? How do the symptoms of each interact?
Outline How do we best treat? Adults Adolescents
What is trauma? An event where a person is exposed to: death threatened death actual or threatened serious injury actual or threatened sexual violence The event may be experienced via: direct exposure witnessing, in person indirectly (i.e., learning that a close relative or close friend was exposed to trauma) repeated or extreme indirect exposure to aversive details of events, usually in the course of professional duties May be prolonged or one-off event American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 ). American Psychiatric Pub.
What is PTSD? Most common psychiatric disorder to occur after a traumatic event (conditional probability 1/10) - Intrusive re-experiencing e.g. nightmares, flashbacks - Avoidance e.g. avoid trauma-related thoughts, feelings, reminders - Negative alterations in cognitions and mood e.g. negative thoughts about self and world, self blame, decreased interest in activities and decreased positive affect - Alterations in arousal and reactivity e.g. irritability or aggression, hypervigilance, difficulty concentrating or sleeping Adaptive response to fear that has become maladaptive American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 ). American Psychiatric Pub.
Rates of child and adolescent trauma The 'hidden epidemic' of child and adolescent trauma is an issue of significant public health concern (Lanius, et al., 2010) Alarmingly high rates of trauma exposure (and repeated exposure) experienced by children and adolescents under the age of 18yrs A review of 32 studies conducted across 13 countries concluded that the rates of trauma exposure peak in adolescence, with 70-80% of adolescents having been exposed to one or more traumas (Nooner, et al., 2012) Nooner KB, et al. (2012). Factors related to Posttraumatic Stress Disorder in Adolescence, Trauma, Violence, & Abuse, 13(3), 153-166
Trauma and pervasive impairment Early trauma is associated with increased risk for serious and disruptive problems that persist into adulthood (Anda et al., 2006; Brady & Back, 2012; Wu et al., 2010) Many experience lifetime difficulties in multiple domains of functioning (emotion regulation, interpersonal functioning, cognition and memory) as manifested by: Low educational attainment and unemployment High risk behaviours, aggression, imprisonment, homelessness Chronic physical health conditions (e.g. cardiovascular disease, diabetes, liver disease) Mental health disorders, substance use and suicide High levels of service utilisation across multiple systems ( e.g. health services, mental health and substance use services, child welfare, juvenile justice) The earlier the trauma, the greater the risk for these problems (Scott et al., 2011). Those exposed to multiple traumas are at increased risk for cumulative impairment (Briggs et al., 2012; Cook et al., 2005; Heim et al., 2010)
Trauma among clients entering AOD treatment In Australia, >80% of entrants to treatment report having experienced a traumatic event in their lifetime Dore et al. Posttraumatic stress disorder, depression and suicidality in inpatients with substance use disorders. Drug Alcohol Rev 2012;31:294 302. Mills et al. Posttraumatic stress disorder among people with heroin dependence in the Australian treatment outcome study (ATOS): prevalence and correlates. Drug Alcohol Depend 2005;77:243 9.
Trauma among clients entering AOD treatment Most commonly: - witnessing serious injury or death, - threatened with a weapon, held captive or kidnapped - physical or sexual assault The vast majority have experienced multiple traumas High rates of childhood trauma Event % Total Witnessed serious injury/death 68 Threatened with a weapon, held captive, kidnapped 64 Seriously physically attacked or assaulted 55 Involved in a life threatening accident 50 Great shock other person 42 Sexually molested 31 Raped 25 Involved in a fire, flood, other natural disaster 24 Other extremely stressful event 21 Tortured or the victim of terrorists 8 Direct combat experience in a war 4 Dore et al. Posttraumatic stress disorder, depression and suicidality in inpatients with substance use disorders. Drug Alcohol Rev 2012;31:294 302. Mills et al. Posttraumatic stress disorder among people with heroin dependence in the Australian treatment outcome study (ATOS): prevalence and correlates. Drug Alcohol Depend 2005;77:243 9.
High prevalence of PTSD in AOD clients Not surprising that up to two-thirds of AOD clients have also been found to suffer from post-traumatic stress disorder (PTSD). 100 80 60 40 20 0 84 80 42 41 88 65 78 83 81 46 42 45 Trauma PTSD Kingston et al. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug Alcohol Rev. 2016; DOI: 10.1111/dar.12448. Dore et al. PTSD, depression and suicidality in inpatients with substance use disorders. Drug Alcohol Rev 2012;31:294 302.
PTSD and SUD among adolescents PTSD and SUD often co-occur among adolescents: 70% of adolescents with SUD have experienced a trauma and up to 35% suffer from concurrent PTSD ~ 50% of adolescents with PTSD also suffer from a co-occurring SUD (Giaconia et al., 2000; Deykin et al., 1997; Kilpatrick et al., 2003; Lubman et al., 2007; Nooner et al., 2012)
Harms associated with PTSD+SUD Poorer physical health Poorer psychological health Poorer psychosocial functioning More severe clinical profile Poorer treatment outcomes Physical health Mental health Psychosocial outcomes Mills et al. (2005). Post traumatic stress disorder among people with heroin dependence in the Australian Treatment Outcome Study (ATOS): Prevalence and correlates. Drug and Alcohol Dependence; 77(3): 243-249. Mills et al. (2007). The impact of PTSD on treatment outcomes for heroin dependence. Addiction, 102: 447-454.
Why do SUD+PTSD co-occur? Theories to explain the relationship: - Self-medication hypothesis Self-medication of PTSD symptoms plays a significant role in the development and maintenance of AOD use disorders. The onset of trauma exposure and the development of PTSD symptoms predates the onset of an AOD use disorders in at least half of cases. Chapman et al. (2012). Remission from post-traumatic stress disorder in the general population. Psychological Medicine, 42, 1695-1703.
Why do SUD +PTSD co-occur? Theories to explain the relationship: - Self-medication hypothesis - High-risk hypothesis - Susceptibility hypothesis - Common factors hypothesis Regardless, once have both disorders each serves to maintain/exacerbate the other
Trauma, PTSD, and AOD use are integrally related Improvements in PTSD lead to improvements in substance use but reciprocal relationship not observed - PTSD symptoms do not remit following improvements in substance use. On the contrary, PTSD symptoms may worsen in the absence of substance use, making it difficult for patients to sustain abstinence and increasing their risk of relapse to AOD use A O D P T S D Abstinence / controlled use Highlights the centrality of PTSD improvement in the treatment of SUD+PTSD clients. Back et al. Cocaine dependence and PTSD: A pilot study of symptom interplay and treatment preferences. Addict Behav 2006;31:351 4. Hien et al. Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA s clinical trials network. Am J Psychiatry 2010;167:95 101. Read et al. Substance use and PTSD: symptom interplay and effects on outcome. Addict Behav 2004;29:1665 72. Myrick & Brady. Current review of the comorbidity of affective, anxiety and substance use disorders. Curr Opin Psychiatry 2003;16:261 70. Sharkansky et al. Substance abuse patients with PTSD: identifying specific triggers of substance use and their associations with PTSD symptoms. Psychol Addict Behav 1999;13:89 97. Dansky et al Untreated symptoms of PTSD among cocaine-dependent individuals. Changes over time. J Subst Abuse Treat 1998;15:499 504.
How do we best treat co-occurring PTSD and SUD?
How do we best treat PTSD+SUD? Reluctance to address PTSD among AOD clients: too vulnerable need to address AOD use first Clients being passed between services with little coordination of care Treatment models for PTSD+SUD Sequential Model SUD treated first PTSD treated later Parallel Model SUD treated by Clinician 1 PTSD treated by Clinician 2 Integrated Model Clients prefer this More efficient SUD and PTSD treated at same time by same clinician Marel et al (2016). Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings. NDARC.
Evidence-based integrated psychotherapies A number of integrated psychological therapies have been developed for the treatment of comorbid SUD+PTSD over the two decades Existing approaches may be divided into two types: - non trauma-focused therapies (present-focused) (e.g., Seeking Safety www.seekingsafety.org/) - trauma-focused therapies (past-focused) - Using prolonged exposure repeated retelling and exposure to trauma memories Roberts et al. (2016). Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD010204
Evidence-based integrated psychotherapies Cochrane review concluded that: - there is little evidence to support nontrauma/present-focused individual or group-based therapies - individual trauma-focused therapies delivered alongside AOD treatment can reduce PTSD severity and AOD use Roberts et al. (2016). Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD010204
Exposure-based integrated psychotherapies Exposure-based therapies = gold standard for PTSD Traditionally, considered inappropriate for people with SUD: distressing emotions experienced may be overwhelming (lead to more substance use; put at-risk of selfharm/suicide) Researchers have begun investigating the efficacy of integrated exposure-based programs that address PTSD and AOD use simultaneously. Foa et al. (2013). Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD: A randomized clinical trial. Journal of the American Medical Association, 310(5), 488-495 Roberts et al. (2016). Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD010204
Exposure-based integrated psychotherapies Support for these programs is growing, with an increasing number of studies providing evidence for their safety and efficacy Two large RCTs conducted in Australia. Mills et al. Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. Journal of the American Medical Association, 2012; 308, 690-699. Sannibale et al. Randomized controlled trial of cognitive behaviour therapy for comorbid post-traumatic stress disorder and alcohol use disorders. Addiction, 2013; 108, 1397-1410.
Exposure-based integrated psychotherapies Sannibale et al (2013) compared the efficacy of integrated CBT for PTSD and alcohol use with CBT for alcohol use plus supportive counselling (12 session; n=62). Participants who had received one or more sessions of exposure therapy had twice the rate of clinically significant change in PTSD severity compared to those who received CBT for alcohol use plus supportive counselling. Mills et al (2012) examined the efficacy of a 13 session integrated therapy called Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) among individuals with a range of SUDs (combines CBT for SUD and PTSD, including prolonged exposure), relative to TAU for SUD (n=103). Mills et al. Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. Journal of the American Medical Association, 2012; 308, 690-699. Sannibale et al. Randomized controlled trial of cognitive behaviour therapy for comorbid post-traumatic stress disorder and alcohol use disorders. Addiction, 2013; 108, 1397-1410.
Participants N = 103 % Childhood trauma (pre 16 years) Median age of first trauma (IQR) Total (n=103) 75% 8yrs (5 15yrs) 55 Treatment (53%) (receive COPE) Percent 30 20 10 0 21 Main drug of concern 19 17 16 48 Control (47%) (assessment only) 12 7 7 1 % CSA 55 % Current PTSD 100 Median duration (range) % Severe depression % Screen +ve for BPD 10yrs (1mth 40yrs) 69 73 100% substance dependent Median number of drug classes used = 4.0 80% injecting drug users % Attempted suicide - Lifetime - 12 month 53 10
What we found Across the 9 mth follow-up period both groups evidenced improvements in their: Substance use Severity of dependence PTSD symptoms Depression Anxiety THEY DID NOT GET WORSE! Participants randomised to COPE demonstrated significantly greater improvements in relation to their PTSD symptoms Mills KL et al (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. JAMA; 308: 690-699.
Primary outcomes PTSD symptom severity Severity of SUD Mean CAPS scores 100 80 60 40 20 0 91.1 89.4 75.9 73.4 68.9 67.9 67.2 52.9 COPE Baseline 6 weeks 3 months 9 months TAU Mean number of dependence criteria 6 5 4 3 2 1 0 5.6 5.3 3.4 3.0 2.6 2.5 3.0 2.3 Baseline 6 weeks 3 months 9 months COPE TAU Mills KL et al (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. JAMA; 308: 690-699.
PTSD diagnosis Percent 100 90 80 70 60 50 40 30 20 10 0 100 100 Baseline Treatment OR 4.21 (1.43 12.45) * 81.6 53.8 Follow-up Control * Controlling for baseline severity of PTSD symptoms
Mean CAPS scores Primary outcomes 100 80 60 40 20 0 PTSD symptom severity 91.1 89.4 75.9 Baseline 73.4 67.2 68.9 COPE Changes in PTSD 67.9severity were NOT influenced by presence 52.9of TAU other comorbidities (depression, anxiety, BPD), types of traumas experienced, types/number of substances used 6 weeks 3 months 9 months Ongoing AOD use may impede therapy, but it is not necessary to achieve abstinence before the commencement Severity of SUD of PTSD treatment improvements can be obtained even with continued AOD 6 use Mean number of dependence criteria 5 4 3 2 1 0 5.6 5.3 3.0 3.4 2.6 2.5 3.0 2.3 Baseline 6 weeks 3 months 9 months COPE TAU Mills KL et al (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. JAMA; 308: 690-699. Mills et al Integrated exposure-based therapy for co-occurring posttraumatic stress disorder (PTSD) and substance dependence: Predictors of change in PTSD symptom severity. Journal of Clinical Medicine, 2016; 5(11), 101.
Participant feedback The best thing I have done for myself in years. I hadn t ever spoken about this stuff so it was really helpful It helped me realise how much my addiction is linked to the trauma. I can now talk about the incident without freaking out No one had ever talked to me about my trauma before. It was good to put a name to my symptoms The imaginal exposure was the hardest part but also the most useful.
Treatment manual The COPE Treatment manual is published in the Oxford University Press 'Treatments that Work' series and available online Back, SE, Foa, EB, Killeen, TK, Mills, KL, Teesson, M, Cotton, BD,... Brady, KT, Concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE): Therapist guide. 2015, New York, NY: Oxford University Press.
Further research (COPE) Persson et al (2017) conducted a pilot study of COPE among 22 women in Sweden. Significant reductions in all efficacy-related outcomes, including PTSD and depression symptom severity, alcohol use, craving, and dependence severity. Ruglass et al (2017) compared the efficacy of COPE and Relapse Prevention Therapy (RPT) for substance use relative to an active monitoring control group (n=110). Both groups demonstrated significantly greater reductions in PTSD and SUD compared to active monitoring. Participants with full PTSD (vs subthreshold) demonstrated significantly greater reductions with COPE relative to RPT. Back et al (in prep) compared the efficacy of COPE to TAU among military veterans (n=54) outcomes pending. Persson, A., Back, S. E., Killeen, T. K., Brady, K. T., Schwandt, M. L., Heilig, M., & Magnusson, Å. (2017). Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE): A Pilot Study in Alcohol-dependent Women. Journal of addiction medicine, 11(2), 119-125. Ruglass, L. M., Lopez-Castro, T., Papini, S., Killeen, T., Back, S. E., & Hien, D. A. (2017). Concurrent treatment with prolonged exposure for co-occurring full or subthreshold posttraumatic stress disorder and substance use disorders: A randomized clinical trial. Psychotherapy and psychosomatics, 86(3), 150-161.
Where to next: Treating substance use and traumatic stress among adolescents There is a critical need to intervene early before PTSD and SUD develop into chronic, relapsing conditions in adulthood Lack of empirically validated treatments for adolescents with PTSD and AOD NHMRC-funded RCT Examining efficacy of COPE-Adolescent treatment in adolescents with co-occurring PTSD + AOD use, relative to a supportive counselling control
Where to next: Currently recruiting in Sydney region We are looking for 12-18 year olds with- Exposure to at least one traumatic event DSM-5 full or subthreshold PTSD diagnosis Use of alcohol or other drugs in past month and history of problematic use Fluency in English Both treatments: 16 sessions with psychologist, free of charge Four optional caregiver sessions Can continue seeing regular clinician Location convenient to participant Further information: http://www.copea.org.au/ Contact: n.peach@unsw.edu.au or k.mills@unsw.edu.au